HomeMy WebLinkAbout030-2019-10-000 (2)
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Form- STC - 1`)4
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC. _ T N-R W
ADDRESS ST. CROIX COUNTY, WISCONSIN
A
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of 11RR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: 11`x_ L:i.claz:id Capacity: 1
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Fron jo: Sideo Rear, 0~_ feet.
From nearest property line Front. vide 7hear ) feet
Number of feet from: well iding:
(Tn,•0da this information of the above plot p!an)( 2 reference d-Lmvnsions to septic tank)
SEE REVERSE SIDE
Cw:78/8 .
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495-00 6 ( ) '
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR 81 HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7"99 BUREAU OF PLUMBING
MADISON, WI 53707
z 12YEONVENTIONAL ❑ALTERNATIVE State Plan I.D Number.
` (if assigned)
` El Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ::r:R R ESS OF PERMIT FOLDER INSPECTION DATEDon Roettger . R. 1, t. Joseph, WI 54082
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.'. JCST REF. IT ELEV
NE NW, Section 1, T29N-R20W, Town of St. Joseph
Name of Plumber MP/MPRSW Nr~ ~C<~u nrv Iary Perm it Nu tuber
Richard W. Hopkins 1059 1 St. Croix 74981
SEPTIC TANK/HOLDING TANK:
MANUFACTUR EH LIQUID CAPACITY TANK INLELLV TANK OUTLET ELLV IWARNING (ABEL LOCKING COVER
/ O PR CT PROVIDED
A-
~ tla L` r/❑NO ❑YESNO
YES
BEDDING. VENT DIA.. VENT MATE HIGH WATER NUMBER OF ~ROAD. o ERTY WILL BWLDING VENT TO FRESH
ALnR
( FEET FROM LINE AIR INLET.
❑YES ❑'NO ❑YES t NO NEAREST
DOSING CHAMBER:
MANUFACTURER BEDDING. UOUID CAPACI TV PUMP MODEL I,IP SIPEU ?pnNUl 'li]LIHtEI WARNING LABEL LOCKING COVER
PROVIDED PROVIDED.
❑YES ❑NO ❑YES L -NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERA oNAL NUMBER OF PtRTV WELL BUILDING IF
NTTOFRESH
(DIFFERENCE BETWEEN FEET FROM 41R INLET
PUMP ON AND OFF) EIYES ENO NEAREST
rN
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing T nME rE I. AT[ HIAI AND MAHKwG
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) ( MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH No OF UISTH PIPE SPA( 1%, COVER [NSH,E )IA -PI*: LIQUID
ST H TRENCHES ;rATLHIAL'. PIT DEPTH
DIMENSIONS Z--
C~RAVEL DEPTH FILL DEPTH DISTH PIP )IL E DI STR . PIPE MATERIAL NO DIS}V21 NUMBER OF PH OPERTV WELL BUILDING VENT TO FRESH
I
BELOWPIPES ABOVECOVEH EIt E
V INLET ELET [NO PIPES FEET FROM LINE AIRIN~.FFT -
- NEAREST -o-
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑YES ❑NO _
SOIL COVER TEXTURE P[HMANINI4+ATtkIH:S - obsEE¢vannNwlus
DYES ❑No 1-1 YES ❑NO _i
DEPTH OVER TRENCH BED DEPTH OVEH TRENCH BEU ITOPSOIL
Sr r!iDf U ,FE DEO 11,1111-CHID
CENTER EDGES
❑YES 1_1 NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGiH NO. OF LATERAL SPncING (HAVEL OFPTH Bf I OW PI Pt FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MnNI F OLD DISTR. PIPE MANIFOLD MATERIAL NO DISTH UISTR PIPE DISTHIBUf ION PIPE Mn7EHIAL & MARKING
EIEV. Et EV DIA ELEV PIPES DIA
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE ROLL SPACING, DHILLE D CORFt FCI L V COVER MATEHIAL VERTICAL LIFT COHRESPONDS TO APPROVED
1 PLANS
❑YES ❑NO L-JYES ❑NO
COMMENTS: PERMANENT MARKERS J OBSERVATION WELLS _ NUMBER OF PH OPE RTV WELL BUILDING
FEET FROM uNE
l '7 ❑YES ❑NO ❑YES l_]NO NEAREST
L~T
~
i
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE - TITLE
DiLHR SBD 6710 (R. 01/82)
r
wisconsn APPLICATION FOR SANITARY PERMIT
D I L H COUNTY
U oEPRY]TmEnTOF (PLB 67) UNIFORM SANITARY PERMIT #
InOUSTRV,LRBOR 6 HurnRn RELRTIOns
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER. MAILING ADDRESS
PROPERTY LOCATION CITY: !
'1f 114 /4, S , TO? N, R --0 E (or)'W TNIEARES N oL ~ r
'LOT NUMBER BLOCK NUMBER SUBDIVISION NAME ROAD, LAKE OR LAfVDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED Q do - C-26 A/ -IQ-
1 or 2 Family Number of Bedrooms:
Public (Specify):
3
THIS PERMIT IS FOR A:
❑ New System Tank Replacement ❑ Repair
Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
XSeepaye Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total # of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
J
Septic Tank Capacity 1 U C'
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
manufacturer: l )
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
C 1
~rX Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print Signatur,/MPRSW No.: Phone Number:
1,~5') 1Ve ri
Plumber's A))dress: amegf Designer:
i
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
Disapproved
' L' " r J p C" ❑ Owner Given Initial
XApproved Adverse Determination
eason for VDisapproval
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
' s
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
APPIACA' IH11 I'OR :~ANI'l'AItY PL:RlI1.'1'
T C 100
This application form IN to he rompIatcd In Pull and signed by the owner(s) of the
property Mug devcl-oiled. Any inadequacies will only result in delays of the permit
issuance. Should Lhis duvelc)puu.nt'be Intended for resale- by owner/contractor, ("spec
House"), then a second J"um shouLd he roLalned and completed when the proppriv
sold and submitted to IhIA offiCa with the appropriate deed recording.
- - - - - - - - - - - - - - - -
Owner of Pro )ert ~ D ~ ~ ~ •
Location of Property ~Cl~%t;, coon f , T N - R C~ W
Township a/ ac",F-'s
Mailing Address _ gC',If
Subdivision name
Lou Number -
Previous Owner of Property Z C(r- `
Total- Size of Parcel ~..7 q `yo!75
Date Parcel was Created
Are alI corners and lot lines identiI1at)le? Yes No
is this property i,ui,ll, ficvelcpe; for re:,<, I e (spec house) Yes _ No
.-7 x-.2115` 4 7Z *7
Volume / - and Pale Number J07 as recorded with the Register of Deeds
INI'I,III11: WITH `fill'; AI'I"I II'ATIi~11 ()Hl? OI-' Till" 1,01,I.0WINC:
1. Warranty 1h 1~1
2. l.rn)d Coat rn "I
3. Other rucf.,idingii Wad i,,ltl I lm I(cqlst.er- of Deeds Office
In addition, a ccrt 101 ad MurVVy, 11 nvo 1 I "hl f., would he helpful- so as to avoid delays
of the reviewing pr"cvn". If thu d„pl da Iptlon references to a Certified Survey
Map, Chu the Cert-I f l ud Survey Map sha 1 I o I n" he required.
- - - - - - - - - - - - - - - - - - - -
PNOVLRVV OWNER CLULRICA7ION
I (we) cut- A that f f(' b.tct.te,ne)1"ts ort this KOoM ane Chue to the best o6 my (OUA)
knowtedrle; that I (we ) curt (and .the. owyto A ) o6 the poopenty dcZI onibed .tn thi,5
.LQonmatton JoAm, by vAllie o6 a wai,va y decd neconde.d .tn •t/te 066tice 06 ,tke
CouHty Regi.6-tet. 06 -003, as vocomcrit V ; and that I (we)
pomerttty oun .the. pooposed hVe 62 the 630agn allpona- hys.tem (on I (we) have
ob.tAned an ease.rrient, to An" Wh the aboov dese&bed paopsa,ty, bon the
constAuctior o6 said ltts.tem, and the some hrts been duty adcolded,.i,n .the.066.ine
r)
o6 the Courtit y,Regi15 ten f)6 Avon, nn !f~f~t moot No, fC, i~ "A t,"z
SIGNATURE C OWNER SIGNATURE 01' CO-OGJNI R (1F AI'I'LICAi31 L.)
S [CNED
DATE S LCNED DA 1,
H
r-{
S T C - 105 r
y
SEVT LC TANK MAINTENANCE ACH L E EN 1' ~
o
Sc. Croix County
0
OWNEH/HUYEk
IZ(li; i'f:/ fsU:{ P:Ulllil:h /~~Z ~S Fi ru Numbs
C 1 I' 'i 1 ; ~ L A ' 1' 1': ~ Pry'. / ~'~✓G~~ C~~wC~ - - 1, l N
N H H I' F R Y 1. T U C AT 1 t) C! i N , 1:
't'own o1- -57-7 St Croix C:ounLy,
Subdivision At~~1' LuL number
i
improper Una anti maiutunaucu of Your sc•i,tic system could resul-L in
iLn urun:aturu lailuru Lo hAudlu waste;;. 1'ropur ❑ua.intuuauc:e c:on-
nint-n of puwpiur out Chu sc ptfc Lank ovary Lhree years or n"onur,
it nvcdud, by a l is unnecl scp1hc tank pumpri. What- you put into
Lhc yKLvm Can ,al 1 A Abe t uucl iou of the wpt is Lank as A Lreat-
munt :tL"gu to the wasLc dinpotsal system.
SL. Croix county rusideuLs mny be uligibiu Lo receive a granl- for
a WAX Imum of 00% of Lhe Cost of ruplaCOMOHL of a tall iU synt-etll,
which was iu opuration prior Lo July 1, 19/8. St. Croix CuunLy
accepted this program in "gust of 198b, with Chu ruquirumenL that
ownern of a1-i uew systems ""rue to kucp thcir systems properly
ilia i.n Lai nei
The prope t 1 y owner agrccs Lo submit- Lu SL. C Vo i CounL Z ail i uy .1
ccurt RICAL l"n form, signed by Lhc owner and by a writer plumber,
journeyman plumber, real ric t_ud p l umber csr .t l i c_ensud pumper ver i.-
Lying that- (1) Cite uu-site wast-ewacur disposal- syst-am is in proper
opcrall Lug condlL Lou and (2) all tar i"nprc t- iou and pumping ( if nue-
assary), Chu supLic_ Lank in less Lhau 1/1 iul..l of sludge and scum.
Ccrrifi-CaLiou form will bu scnL approximately 30 days prior co
three year cxpirat-ion. o
Chu undersigned, havc,_ read Chu above requirements and agree
Co Waintaiu the private sewage disposal- sy_stcm in accordance with
the standards set forth, herein, as sat b_v the Wisconsin Depart- w
taunt of NaLuraL 1Cu6ourcus. GerLitical-ion form must: be tompluLed
and returned Lo the St. Croix CounLy Zoning Off k ye wichiu 30 days
of Lhe thrcu year uxpiraLi"n date.
I
SICNCU -1 pAG,
DATE, 105
o~
St. Croix County Zoning; Olt ice
P.O. BOX `.b.
Haman itd, WL 540L5
71 5- 96-2239 or 715-425-8363
Sign, date and return to above address.
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS MADISON, WI 53707
(H63.09(1) & Chapter 145.045)
LOCATION`: SECTION: OWNSH-/Mt UNICIPLITY: LOT, ; BLK. O.: SUBDIVI ON NAME:
v1/ (or g, Al All~ CNTY: OW ER'S/BUYE 'S N E: MAI IN~ ADDRESS:
DGh 1~C/L~ E K' q,~A,
USE DATES O SERVrATIONS MADE
NO. BEDRMS.: COMMEFJCI L DESCRIPTION: PROFIL DES RIPTIONS: PER OLAT ON TEST
Residence ❑New Replace . C'
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TA K:RECOMMENDEDSYS M:(o io )
iS ❑U S ❑U ~S ❑U ❑S U ❑S, U e, , -_Z
If Percolation Tests are NOT require ESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate:
Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
e 2 ~5 ~X , /S C"s ~r S I 7 S' r
I'll 161
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P- - r
4' r z
P_
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION 7. Z
rL ,
F J ~ w
Ell
_N
555
.23
, .
,
,
E
,
, .
F
,
E
3 ~I
i
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I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (p nt): TESTS ER COMPLETED ON:
ADD E
1 CER IFI ATION NUMBER: PHONE NUMBER (optional):
2 3
P -3 33 dtlSo,, CS7 ce) '3WV7
CST I AT
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) -OVER -
L
1 MAX MPYA cur be of Ot<< hits w con „am . u, , a ,r=
PLEASE use die r bbi vAt"i s shown new , for w,ti ,>yi pro!„ He ties,, ipis o s 3rnd
ii.[„KE A LEGIBLE tlwa` wn rsf. uo: My k5c.titmy =i:.itY ten .e:€t.;aC'.i.7r`fS Ia j,,° inq to scale is prefe rod,
a .,;:e sheet dna, E usyl if :?wed:
a
t _ is y[,L<; ,;r , €-t rk and tKh al ple allan i chum n"e r aP tltcatip,i-!,
w Ase H app;,inp one hams as to owes, names, adilou=' E M=ain a
he i=' o ,r,i=p ( ,?."'fin a E hod d on, m .inai m) # ocn F r (u 1
Svh-'C' travel, 10") IR But.
- Get ttd t -sa? T'LS - 4 ta,rVw%
Af
Cow. Smal N
Mnewn, Sold IN VVY
F d
T ?
SmAy o
13m,
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y
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FRESH All' -I:I' 1"I;"I'S AND OBSERVA,rion P*r-PL
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Approved Vent Cap
Minimum 12" Ahovc
-Final Gr~1c~c
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i 4" Cast Iron
Above Pi r\..-- -
Pe Ve n f_ Pi-pe
To Final Gr.adr -
Marsh Iiay Oi-- Synthetic Cc:ver_-i )q
Min. 2" Agg.re1j-11;,,
Over Pipe I~
DisLribuLion ` - - c,- Tee
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f Aggregate _ _ Pei f orzl t_-ed Pipe Below
• Beneath Pipe <_-__--coup .ing Ter_minaL .ng At
S y s t e m
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